Spontaneous pneumomediastinum presenting as jaw pain during labor.

BACKGROUND: Pneumomediastinum, or presence of free air within the mediastinum, is a rare complication of labor. Common symptoms of this condition include chest pain, dyspnea, and subcutaneous emphysema. CASE: A woman complained of right jaw pain 90 minutes after the onset of her second stage of labor. On examination, she was found to have swelling and crepitus over her face, neck, and supraclavicular region. A chest radiograph demonstrated a pneumomediastinum, which resolved spontaneously. CONCLUSION: Pneumomediastinum is associated with Valsalva maneuvers such as those seen during the second stage of labor. We report jaw pain as an unusual presenting symptom of this rare condition. Familiarity with the presenting symptoms of a pneumomediastinum is imperative for appropriate treatment and monitoring for significant complications.

Group B streptococci causing neonatal bloodstream infection: antimicrobial susceptibility and serotyping results from SENTRY centers in the Western Hemisphere.

OBJECTIVE: Group B streptococcal infection is a common cause of neonatal sepsis. Surveillance of antimicrobial susceptibility and serotype frequencies of invasive group B streptococci is important to ensure the effectiveness of therapeutic regimens and to guide vaccine development. STUDY DESIGN: Prospective surveillance of neonatal bloodstream infection was performed at all Western Hemisphere sites participating in the SENTRY Program. From January 1997 through December 1999, a total of 122 isolates of bloodstream infections with group B streptococci were collected and sent to the University of Iowa for antimicrobial susceptibility testing and serotyping. RESULTS: No isolates were resistant to penicillin. More than 25% of isolates from US hospitals and 14% of isolates from Canadian hospitals were erythromycin resistant. Seven percent of isolates from the United States and Canada were resistant to clindamycin. No clindamycin or erythromycin resistance was found among isolates from Latin America. Clindamycin and erythromycin resistance was most frequent among serotype V strains. CONCLUSIONS: No emerging resistance to penicillin was noted among bloodstream infection isolates of group B streptococci from a broad geographic area; erythromycin and clindamycin resistance was found in the United States and Canada and appeared most frequently among serotype V strains.

Computed tomography in endometrial carcinoma.

OBJECTIVE: To determine the value of computed tomography (CT) scans for preoperatively detecting extrauterine-nodal disease and postoperative recurrent disease in patients with endometrial cancer. METHODS: We reviewed records of 702 women with primary endometrial carcinoma that was diagnosed between 1979 and 1993. Preoperative CT findings were compared with pathologic findings to assess nodal disease. The yield of postoperative CT was reviewed in clinically suspicious and routine settings. RESULTS: Among 492 women eligible for analysis, 178 (36%) had a total 326 CT scans. Among 56 women who had preoperative CT scans and lymph node samplings, positive and negative predictive values for nodal involvement were 50% and 94%, respectively, and sensitivity and specificity were 57% and 92%, respectively. Preoperative CT findings altered treatment plans in only six patients (8%). Forty-five asymptomatic women had 73 routine CT scans, and recurrence was diagnosed by CT in only two (4.4%). Thirty-seven women had CT scans for suspicion of recurrence, which was confirmed in 17 (46%). Kaplan-Meyer analysis showed no survival advantage in women with subclinical recurrences diagnosed by CT scan. CONCLUSION: Routine preoperative CT scanning rarely alters treatment and is a poor predictor of nodal disease. Computed tomography in the postoperative period might be helpful for detection and follow-up of recurrent disease, but there was no difference in survival when subclinical recurrence was found by CT. Thus, CT scanning of any woman with endometrial cancer should be discouraged unless it is to evaluate symptoms.

A large simple randomized trial of rocuronium versus succinylcholine in rapid-sequence induction of anaesthesia along with propofol.

BACKGROUND: Rocuronium has an onset of action more rapid than other non-depolarizing neuromuscular blocking agents, but it is unclear whether it and succinylcholine give equivalent intubating conditions during rapid-sequence induction of anaesthesia. We performed this study to answer the question--are there clinically relevant differences between the use of rocuronium and succinylcholine to secure acceptable intubating conditions during rapid-sequence induction of anaesthesia with propofol? METHODS: Anaesthesia was induced using propofol 2.5 mg/kg in 349 ASA physical status grade I-IV patients who were undergoing either elective or emergency surgery. Propofol was followed immediately by either rocuronium 0.6 or 1 mg/kg or succinylcholine 1.0 mg/kg (randomly selected). Fifty seconds after the end of muscle relaxant injection laryngoscopy was performed and intubating conditions were graded by an experienced anaesthetist blind to the muscle relaxant allocation. This study design was selected so that a 10% difference in clinically acceptable intubating conditions between drugs would be detectable. RESULTS: In this setting rocuronium 1.0 mg/kg provided superior intubating conditions compared with rocuronium 0.6 mg/kg. The incidence of clinically acceptable intubating conditions with rocuronium 1.0 mg/kg and succinylcholine 1.0 mg/kg was 93.2% and 97.1% respectively, the difference being -3.9% (95% C.I. -9.7% to 1.9%). CONCLUSION: Rocuronium 1.0 mg/kg given along with propofol in a rapid-sequence induction of anaesthesia is clinically equivalent to succinylcholine 1.0 mg/kg.

Obesity and prognosis in endometrial cancer.

OBJECTIVE: We tested the null hypothesis that morbid obesity as measured by the Quetelet index has no influence on survival in endometrial cancer. STUDY DESIGN: A retrospective study of 492 women with endometrial carcinoma was performed. Age, height, weight, Quetelet index, stage, cell type, grade, node status, peritoneal cytologic findings, and depth of myometrial invasion were analyzed for influence on survival. RESULTS: Mean Quetelet index was 34 (range 16 to 89). Quetelet index was < 30 in 45% of patients, 30 to 40 in 33%, and > 40 in 22%. Five percent of those with a Quetelet index > 40 had positive nodes, but 64% of patients with a Quetelet index > 40 did not have lymph node sampling done. Lack of sampling of lymph nodes in the entire group had no adverse effect on survival. In a proportional hazards regression model for time from diagnosis to death from disease, grade, node status, myometrial invasion, and stage had highly significant effects. When Quetelet index was analyzed as a continuous variable, as Quetelet index increased, time to recurrence was significantly increased (p = 0.0136), and significance was approached for survival (p = 0.0645). Quetelet index was strongly related to grade (p = 0.013), depth of myometrial invasion (p = 0.031), negative cytologic findings (p = 0.004), and stage (p = 0.011) with obese patients having better differentiated, less invasive tumors of lower stage with negative washings. CONCLUSIONS: Morbid obesity positively affects survival in endometrial carcinoma. This effect is accounted for by the association of obesity with less aggressive disease. Morbid obesity is not associated with increased death from other causes. Lack of sampling of negative lymph nodes does not adversely affect survival.

Successful resuscitation from sea water drowning.

A case of a 24-year-old male who survived a near drowning despite suboptimal pre-hospital management is reported. The case illustrates the value of continuing resuscitative efforts even in the apparently dead drowning victim.